The learning paradox

“I am slow to learn and slow to forget that which I have learned. My mind is like a piece of steel,
very hard to scratch anything on it and almost impossible after you get it there to rub it out.”
– Abraham Lincoln

Despite his demonstrated capacity for significant life accomplishments, I’m not sure how well our 16th president would have liked being a medical student in the 21st century. Modern medicine is an expanding body of knowledge, but the brain is a relatively static piece of biomachinery. The amount of knowledge that a medical student must acquire in order to pass the first step of the licensing exam is considerable and seems to grow daily. The reality is that there’s not enough time to learn it to the point where one can consider the knowledge etched in steel in one’s mind. I can’t tell you how many times I’ve talked to upperclassmen, residents, and even practicing physicians who report that the learning in their careers has been matched by an equal amount of forgetting. Like Lincoln would, most of us have to cram knowledge into our brains in order to pass exams, only to later find that our brain’s hold on it is ephemeral.

How do most students deal with the rising tide of knowledge? Study harder, dose themselves with stimulants, sleep less: these are some popular strategies. They’re popular because they more or less work – almost all students pass classes and exams using a combination of these three methods. But is this the best way to learn? What about retaining those details that might not be useful on a day to day basis, but incredibly important to treat that rare disease only encountered once in one’s career?

In the brain, the hippocampus is critical for creating episodic memory, but it has been hypothesized that long term storage results from the restructuring of information across the hippocampal-neocortical networks over time, resulting in a distributed memory representation. Research has found enhanced hippocampal-cortical interactions during rest following an experience; the magnitude of resting correlations predicted associative memory down the road. In other words, taking a break after learning something is an integral part of the learning experience. This is what I believe Lincoln was getting at in the quote above – truly mastering material such that it never leaves you is a process that cannot be rushed; it is a combination of learning and reflection.

But being rushed describes a dominant component of our lives as medical students. I don’t know any students that don’t love breaks – without conducting a formal study, I’m going to venture to say that nearly 100% of my cohort reports enjoying breaks on a regular basis. So why don’t we take more of them? Despite the cognitive advantage and self-evident awesomeness of resting, being in medical school (not to mention surfing the web for articles to back up one’s hunches) is a constant reminder that there is more to learn than we could possibly handle, even without taking any breaks.

So the struggle continues unabated, between our attempts to rest our brains (and our overall sanity), and the struggle to pass our tests so we can continue on with our education. How much effort is actually enough is complicated by the fact that an individual only goes to med school once, and every course is different – you never know how much work you’ll have to do until it’s all over and you’re reflecting on your previous efforts (assuming you have time to reflect; more likely, you’re preparing for the next exam). It isn’t necessarily pretty, but the overall process does work more or less. But given how information technology is changing the value of memorizing large quantities of information, I wonder if there’s a way to restructure medical education to harness the power of rest to make medical students wiser, more reflective learners.

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Rob West

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